Embed Size (px)
Citation preview
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a
complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under
“Employee Benefits.” www.leusd.k12.ca.us
2018-19Employee Benefits Booklet
Admin-Cert/Class/Conf.
Lake Elsinore Unified School District
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a
complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under
“Employee Benefits.” www.leusd.k12.ca.us
Benefits Eligibility
Employee Eligibility In general, you are eligible for medical, dental, vision, and life insurance benefits if you
are:
A probationary or permanent employee; and
You work 20 hours or more per week in your regular assignment.
If you are a represented employee, we encourage you to review your collective
bargaining agreement (CBA) each year to verify your specific eligibility requirements.
Dependent Eligibility If you enroll yourself in District benefits, you can also enroll your eligible dependents.
You must provide appropriate proof of the dependent relationship when you enroll your
dependent (see below). You must enroll yourself and your dependents within 30 days
of becoming eligible for District benefits. You may enroll eligible dependents at the
same time you enroll yourself.
Eligible dependents include:
Your legal spouse as defined by state law. (Required documentation: a
marriage certificate & current IRS 1040)
Your California-registered domestic partner subject to AB 205. A California-
registered domestic partner is the same gender as you or may be opposite-gender
only if at least one partner is over age 62. (Required documentation: a certified
copy of the Declaration of Domestic Partnership filed with the Secretary of State.)
Domestic Partner not subject to AB 205: Signed notarized SISC affidavit
A natural child or step-child from birth to age 26; a legally adopted child or a
child who is in the process of being adopted; a child for whom the member has
legal and physical custody/guardianship. A child who is in the process of being
adopted is considered legally adopted when SISC receives legal evidence of (i)
the intent to adopt; and (ii) the member has either: (a) the right to control the
health care of the child; or (b) assumed a legal obligation for full or partial
financial responsibility for the child in anticipation of the child’s adoption. Proof
of eligibility will be required when adding a new dependent for an existing
employee and at the time of hire for a new employee. Failure to submit
supporting documentation within 30 calendar days of the qualifying event may
result in the child or child of a domestic partner being denied coverage.
Disabled Dependent: A disabled dependent may be eligible to continue
coverage beyond age 26 if unmarried and a dependent for Federal Income Tax
purposes (proof required); the member must request a Disabled Dependent
Certification form within 30 days of the loss of coverage. The completed and
signed form must then be reviewed and approved by the carrier’s Medical Review
board.
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a
complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under
“Employee Benefits.” www.leusd.k12.ca.us
Who must enroll in coverage: All employees who work 90% or more of the
full-time equivalent for the applicable job classification are required to participate
in all health benefits offered by the district. If the district has a three-tier rate
structure, dependent coverage is optional for those products. An eligible
employee who works less than the 90% may enroll when first eligible or decline
coverage.
Your Cost for Benefits If you are eligible for District benefits, there is a CAP that is contributed by the District
according to your CBA. This information is available later in this summary. If you are a
part time employee, the percentage of the CAP will be calculated according to your
assigned hours per day and months per year. The deductions are monthly according to
the number of paychecks you receive (11 or 12) per year.
When to Enroll The District’s plans are effective October 1 through September 30. You must enroll
yourself and your dependents within 30 days of becoming eligible for District
benefits. You may enroll eligible dependents at the same time you enroll yourself.
You are allowed to enroll in benefits and make changes to your benefits only:
When you are initially eligible;
During the annual Open Enrollment period; or
If you experience a qualifying status change.
****If you do not come in within the 30 days, you will automatically be enrolled in
the Bronze Tiered PPO Plan (Affordable Care Act) by the Safety/Risk Department.
The Bronze Tier plan premiun is under the District contribution amount so there is no deduction.
Enrolling When you are First Eligible You must enroll yourself and your dependents within 30 days of becoming eligible
for District benefits. You may enroll eligible dependents at the same time you enroll
yourself.
Please note: Employees with a hire date from the 1st thru the 15th of the month, benefits
will be effective on the first day of the following month (i.e. DOH-January 10th, benefits
will be effective February 1st). Employees hired after the 15th, benefits will not be
effective for up to 45 calendar days (i.e. DOH-January 16th, benefits will be effective
March 1st).
Making Changes During Open Enrollment Once you have enrolled in benefits, you generally are not allowed to make changes until
the next annual Open Enrollment. Open Enrollment is your one chance each year to
review your coverage and make changes to your benefits. It is also your chance to enroll
if you declined coverage when you first became eligible.
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a
complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under
“Employee Benefits.” www.leusd.k12.ca.us
Open Enrollment is usually about August 1st to August 24th; any changes made during this period take effect October 1st.
Making Changes During the Year
Other than during Open Enrollment, you can make changes to your benefits during the
year only if you experience a qualifying status change. Any changes must be made
within 30 days of the qualifying status change. A qualifying status change might
include:
A change in family status, such as marriage or registration of a domestic
partnership, the birth or adoption of a child, divorce or dissolution of a domestic
partnership, or the death of a dependent. You must provide the benefit department
with proof of the event (such as a marriage certificate, birth certificate, death
certificate, divorce order, or court order.)
The loss of existing coverage for you and/or your eligible dependents (for
example, the termination of coverage that was provided through your spouse’s
employer). Please provide proof of loss with date and names.
A qualified court or administrative order that requires you to provide coverage
for an eligible dependent.
Any benefit changes must be consistent with the qualifying status change. Provided you
make changes within 30 days of the event, the change will take effect on the date of the
event for a birth, adoption, or placement for adoption; changes you make as a result of
other qualifying status changes will take effect the first day of the month after you submit
the appropriate documentation to Safety & Risk Services department.
AMERICAN FIDELITY: IRS 125 Plan
*Flexible Spending Accounts-Unreimbursed Medical/Child Dependent Care
As part of the Section 125 Plan these benefits are available on a pre-tax basis for your
school district (Unreimbursed Medical and Dependent Daycare expense reimbursement
accounts). A Section 125 Plan allows you to select from a list of eligible benefits that
will meet your needs. The benefits that you choose are then paid for by you on a before-
tax basis. Salary reduction means that you are able to use "pre-tax" dollars to pay for
certain benefits that you may have previously paid for with "after-tax" dollars.
Voluntary Plans Available: American Fidelity (866) 523-1857 Aflac : Agent Mary Isaacs (951)264-2100
*Disability Insurance
A Disability Income Insurance Plan can provide a portion of your income during your
covered Accident or Sickness. SB-22577-0209 (LEUSD employees do NOT pay into
SDI: State Disability Insurance)
*Accident Insurance*Cancer Insurance*Life Insurance
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a
complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under
“Employee Benefits.” www.leusd.k12.ca.us
An Overview of Your Benefits
The District offers you and your eligible dependents a comprehensive selection of health
and welfare benefits.
Your medical benefits are designed to help maintain the wellness and health of you and
your family. The District offers two types of medical plan options: HMO and PPO.
With the HMO options, you must receive care from providers in the plan’s network; the
plan won’t pay any benefits for care received outside the network except in an
emergency. With the PPO plan, you have the flexibility to receive care from any
provider; however, the plan will pay a higher level of benefits when you receive care
from a provider who participates in the plan’s network. Keep in mind that certain
benefits in each plan may vary, depending on your bargaining unit.
Health Care Benefits
The District offers six medical plans per classification: 1. Option 1: Anthem PPO with a deductible of $500 per individual up to
$1000 per family- 80%-$30 OV-RX $10/$35/$200 ded.
2. Option 2: Anthem PPO with a deductible of $200 per individual upto $500 per family- 90%-$30 OV-RX $10/$35/$200 ded.
3. Option 3: Anthem PPO with a deductible of $300 per individual up to
$600 per family- 100%-$20 OV-RX $9/$35.4. Option 4: Bronze Tiered Plan-PPO with a deductible of $5000, only
employee + child(ren) is eligible.
5. Option 5: Anthem HMO Priority Select: office copay of $20.
6. Option 6: Anthem HMO: office copay of $20.7. Option 7: Kaiser HMO: office copay of $30 (Rx $10/$30)
The District offers your choice of two dental plans and one vision plan.
1. Delta Dental Incentive Plan (PPO)
2. Delta Dental Preferred Option (PPO) Plan
3. Vision Service Plan (VSP)
Flexible Spending Accounts (FSAs): FSAs give you the option to set
aside pre-tax funds to pay for certain eligible health care and dependent
care expenses. Information is available on the District website
(Employee Benefits) under “American Fidelity 125 Flex Plan”.
Group Life and AD & D: The District provides all benefit eligible
employees with life and AD & D (accidental death & dismemberment) to
help provide financial protection. Voluntary supplemental coverage is
available to employees at an additional cost.
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
plan and insurance documents govern your right and benefits under each plan. For more details about your benefits, including a
complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under
“Employee Benefits.” www.leusd.k12.ca.us
Important Information About Your Benefits
This section includes some important notices about your right and responsibilities as a
participant in the District’s plans. If you have any additional questions about this
information, feel free to contact the Safety & Risk Services department at (951) 253-
7000, ext. 5380.
Important Notice About Your Rights and Benefits Under Each Plan This booklet is intended to provide only highlights of your benefits; it is not an Evidence
of Coverage (EOC) plan document. Official plan and insurance documents govern your
rights and benefits under each plan. For more details about your benefits, including a
complete list of exclusions and limitations, please refer to each carrier’s EOC. A copy of
the EOC can be obtained from the Lake Elsinore Unified School District website:
www.leusd.k12.ca.us.
Notice of Health Insurance Portability and
Accountability Act of 1996 (HIPAA) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal
law that affects your rights to obtain health benefits and to safeguard your privacy
regarding Protected Health Information (PHI). Specifically, HIPAA includes, but is not
limited to, the following:
Limitations on pre-existing condition exclusions;
Prohibitions against discriminating against individual participants and
beneficiaries based on health status;
Special enrollment periods under certain conditions for qualified individuals; or
Privacy standards
COBRA Rights Once an employee and/or dependent lose coverage, SISC prepares and mails the
COBRA 14-day notification to the qualified beneficiary’s last known address. It
includes information and rates on all of the products the qualified beneficiary is enrolled
in through SISC immediately preceding the qualifying event (loss of coverage).
How to Enroll Go to:
1. www.leusd.k12.ca.us
2. Click “Employee Resources”-"Staff"3. Click “Employee Benefits”
4. Click “Confidential Management/Admin Health Insurance”
5. Review all topics, summaries and plans and once your choice is made:
6. Complete the proper enrollment forms and bring to Safety & Risk with proper
documentation for spouse, dependents or opting out of medical.
An
the
m P
PO
An
the
m H
MO
& K
ais
er
HM
O
Ca
p $
10
,92
5P
PO
- O
pti
on
1
PP
O-
Op
tio
n
2
PP
O-
Op
tio
n
3
An
the
m-
Pri
ori
ty
Se
lec
tA
nth
em
- H
MO
Ka
ise
r
Op
tio
n O
ffe
red
Du
e t
o A
ffo
rda
ble
Ca
re A
ct
Re
qu
ire
me
nts
Su
mm
ary
of
Co
ve
rag
e8
0%
90
%1
00
%S
um
ma
ry o
f C
ove
rag
e1
00
%1
00
%1
00
%
**T
wo
Tie
red
An
ch
or
Bro
nze
Pla
n
De
du
ctib
le$
50
0/$
10
00
$2
00
/$5
00
$3
00
/$6
00
Inp
atie
nt
Ho
sp
ita
l$
20
0/A
dm
it$
20
0/A
dm
it$
0$
5,0
00
/$1
0,0
00
***O
ut
Of
Po
ck
et
Ma
xim
um
$2
00
0/$
40
00
$1
00
0/$
30
00
$1
00
0/$
30
00
Co-P
aym
en
t M
ax
$1
50
0/$
30
00
$1
50
0/$
30
00
$1
50
0/$
30
00
$6
,35
0/$
12
,70
0
ER
Co
pa
y$
10
0$
10
0$
10
0E
R C
op
ay
$1
00
$1
00
$1
00
$1
00
Off
ice
Vis
it
Co
pa
y$
30
$3
0$
20
Off
ice
Vis
it C
op
ay
$2
0$
20
$3
03
0%
of
vis
it
Ge
ne
ric R
x R
eta
il C
op
ay
$1
0$
10
$9
Ge
ne
ric R
x R
eta
il C
op
ay
$1
0$
10
$1
0$
9
Bra
nd
Rx D
ed
uctib
le$
20
0$
20
0$
0B
ran
d R
x D
ed
uctib
le$
20
0$
20
0$
0$
0
Bra
nd
Rx R
eta
il C
op
ay
$3
5$
35
$3
5B
ran
d R
x R
eta
il C
op
ay
$3
5$
35
$3
0$
35
Co
mp
osit
e
Co
mp
osit
e
Em
plo
ye
e O
nly
$6
01
Me
dic
al
$1
,30
5$
1,4
88
$1
,59
0M
ed
ica
l$
1,1
69
$
1,3
44
$
1,3
23
2
-Pa
rty +
$9
44
De
nta
l P
PO
$1
22
$1
22
$1
22
Den
tal P
PO
$1
22
$
12
2
$1
22
N
OT
VS
P$
26
$
26
$
26
VS
P$
26
$2
6$
26
Ava
ilab
le
Life
$7
$
7
$7
Life
$7
$7
$7
$7
TO
TA
L$
1,4
60
$1
,64
3$
1,7
45
TO
TA
L$
1,3
24
$1
,49
9$
1,4
78
$6
02
LE
SS
Mo
nth
ly C
AP
$9
10
$9
10
$9
10
LE
SS
Mo
nth
ly C
AP
$9
10
$9
10
$9
10
$9
10
20
18
-19
Pa
yro
ll D
ed
uc
tio
n (
Pre
ferr
ed
)$
55
0$
73
3$
83
52
01
8-1
9 P
ayro
ll D
ed
uc
tio
n (
Pre
ferr
ed
)$
41
4$
58
9$
56
8$
0
20
17
-18
Cu
rre
nt
De
du
cti
on
$5
34
$7
15
$8
15
20
17
-18
Cu
rre
nt
De
du
cti
on
$3
98
$5
70
$5
39
n/a
De
nta
l In
ce
ntive
$8
5$
85
$8
5$
85
$8
5$
85
20
18
-19
Pa
yro
ll D
ed
uc
tio
n (
Inc
en
tive
)$
51
3$
69
6$
79
82
01
8-1
9 P
ayro
ll D
ed
uc
tio
n (
Inc
en
tive
)$
37
7$
55
2$
53
1
20
17
-18
Cu
rre
nt
De
du
cti
on
$4
98
$6
78
$7
78
20
17
-18
Cu
rre
nt
De
du
cti
on
$3
61
$5
33
$5
03
***O
ut
Of
Po
cket
Maxim
um
: I
nclu
des d
ed
ucti
ble
an
d a
ll c
op
ays (
no
t R
X)
***V
SP
-2n
d p
air
of
gla
sses $
20 d
ed
ucti
ble
** T
wo T
iere
d B
ronze P
lan a
vaila
ble
to a
ll em
plo
yees inclu
din
g p
art
-tim
e (
i.e,
substitu
tes &
coaches).
P
art
tim
e a
nd t
em
pora
ry e
mplo
yees d
o n
ot
receiv
e d
istr
ict
contr
ibutions.
Ad
min
/Cert
ific
ate
d P
lan
s 2
018
-19
Co
mp
osit
e R
ate
s/P
ayro
ll D
ed
ucti
on
s
Es
tim
ate
d
An
the
m P
PO
An
the
m H
MO
& K
ais
er
HM
O
Ca
p $
10
,81
4P
PO
- O
pti
on
1
PP
O-
Op
tio
n
2
PP
O-
Op
tio
n
3
An
the
m-
Pri
ori
ty
Se
lec
tA
nth
em
- H
MO
Ka
ise
r
Op
tio
n O
ffe
red
Du
e t
o A
ffo
rda
ble
Ca
re A
ct
Re
qu
ire
me
nts
Su
mm
ary
of
Co
ve
rag
e8
0%
90
%1
00
%S
um
ma
ry o
f C
ove
rag
e1
00
%1
00
%1
00
%
**T
wo
Tie
red
An
ch
or
Bro
nze
Pla
n
De
du
ctib
le$
50
0/$
10
00
$2
00
/$5
00
$3
00
/$6
00
Inp
atie
nt
Ho
sp
ita
l$
20
0/A
dm
it$
20
0/A
dm
it$
0$
5,0
00
/$1
0,0
00
***O
ut
Of
Po
ck
et
Ma
xim
um
$2
00
0/$
40
00
$1
00
0/$
30
00
$1
00
0/$
30
00
Co-P
aym
en
t M
ax
$1
50
0/$
30
00
$1
50
0/$
30
00
$1
50
0/$
30
00
$6
,35
0/$
12
,70
0
ER
Co
pa
y$
10
0$
10
0$
10
0E
R C
op
ay
$1
00
$1
00
$1
00
$1
00
Off
ice
Vis
it
Co
pa
y$
30
$3
0$
20
Off
ice
Vis
it C
op
ay
$2
0$
20
$3
03
0%
of
vis
it
Ge
ne
ric R
x R
eta
il C
op
ay
$1
0$
10
$9
Ge
ne
ric R
x R
eta
il C
op
ay
$1
0$
10
$1
0$
9
Bra
nd
Rx D
ed
uctib
le$
20
0$
20
0$
0B
ran
d R
x D
ed
uctib
le$
20
0$
20
0$
0$
0
Bra
nd
Rx R
eta
il C
op
ay
$3
5$
35
$3
5B
ran
d R
x R
eta
il C
op
ay
$3
5$
35
$3
0$
35
Co
mp
osit
e
Co
mp
osit
e
Em
plo
ye
e O
nly
$6
01
Me
dic
al
$1
,30
5$
1,4
88
$1
,59
0M
ed
ica
l$
1,1
69
$
1,3
44
$
1,3
23
2
-Pa
rty +
$9
44
De
nta
l P
PO
$1
22
$1
22
$1
22
Den
tal P
PO
$1
22
$
12
2
$1
22
N
OT
VS
P$
26
$
26
$
26
VS
P$
26
$2
6$
26
Ava
ilab
le
Life
$7
$
7
$7
Life
$7
$7
$7
$7
TO
TA
L$
1,4
60
$1
,64
3$
1,7
45
TO
TA
L$
1,3
24
$1
,49
9$
1,4
78
$6
02
LE
SS
Mo
nth
ly C
AP
$9
01
$9
01
$9
01
LE
SS
Mo
nth
ly C
AP
$9
01
$9
01
$9
01
$9
01
20
18
-19
Pa
yro
ll D
ed
uc
tio
n (
Pre
ferr
ed
)$
55
9$
74
2$
84
42
01
8-1
9 P
ayro
ll D
ed
uc
tio
n (
Pre
ferr
ed
)$
42
3$
59
8$
57
7$
0
20
17
-18
Cu
rre
nt
De
du
cti
on
$5
43
$7
24
$8
24
20
17
-18
Cu
rre
nt
De
du
cti
on
$4
07
$5
79
$5
48
n/a
De
nta
l In
ce
ntive
$8
5$
85
$8
5$
85
$8
5$
85
20
18
-19
Pa
yro
ll D
ed
uc
tio
n (
Inc
en
tive
)$
52
2$
70
5$
80
72
01
8-1
9 P
ayro
ll D
ed
uc
tio
n (
Inc
en
tive
)$
38
6$
56
1$
54
0
20
17
-18
Cu
rre
nt
De
du
cti
on
$5
07
$6
88
$7
88
20
17
-18
Cu
rre
nt
De
du
cti
on
$3
71
$5
43
$5
12
***O
ut
Of
Po
cket
Maxim
um
: I
nclu
des d
ed
ucti
ble
an
d a
ll c
op
ays (
no
t R
X)
***V
SP
-2n
d p
air
of
gla
sses $
20 d
ed
ucti
ble
** T
wo T
iere
d B
ronze P
lan a
vaila
ble
to a
ll em
plo
yees inclu
din
g p
art
-tim
e (
i.e,
substitu
tes &
coaches).
P
art
tim
e a
nd t
em
pora
ry e
mplo
yees d
o n
ot
receiv
e d
istr
ict
contr
ibutions.
Ad
min
/Cla
ss-C
on
fid
en
tial
Pla
ns 2
018
-19
Co
mp
osit
e R
ate
s/P
ayro
ll D
ed
ucti
on
s
Es
tim
ate
d
Pla
n T
ype (
PP
O o
r H
MO
)P
PO
PP
OP
PO
HM
OH
MO
PP
O
Carr
ier
(Anth
em
Blu
e C
ross,
Blu
e S
hie
ld,
or
Kais
er)
Anth
em
Anth
em
Anth
em
Anth
em
Kais
er
Anth
em
Dis
tric
t N
am
eL
AK
E E
LS
INO
RE
UN
IFIE
D
Barg
ain
ing
Un
itC
ON
F M
GM
T/A
DM
IN
2018-2
019
An
them
An
them
An
them
An
them
Kais
er
An
them
10
0-D
$2
090
-C $
30
80
-G $
30
Pre
mie
r 20
Tra
d H
MO
$3
0A
nch
or
Bro
nze
ME
DIC
AL
- C
AL
EN
DA
R Y
EA
R D
ed
ucti
ble
s &
Maxim
um
sM
em
ber
Pays
Mem
ber
Pays
Mem
ber
Pays
Mem
ber
Pays
Mem
ber
Pays
Mem
ber
Pays
Indiv
idual/F
am
ily D
eductible
s
$300/
$600
$200/
$500
$500/
$1,0
00
$0/$
0$0
$5,0
00/
$10,0
00*
Indiv
idual/F
am
ily O
ut-
of-
(OO
P)
Max
(in
clu
de
s m
ed
ica
l d
ed
uctib
les,
co
-in
su
ran
ce
an
d c
o-p
ays)
$1,0
00/
$3,0
00
$1,0
00/
$3,0
00
$2,0
00/
$4,0
00
$1,5
00/
$3,0
00
$1,5
00/
$3,0
00
$6,3
50/
$12,7
00*
*
Inclu
des R
x
PR
OF
ES
SIO
NA
L S
ER
VIC
ES
Off
ice V
isit (
OV
) co-p
ay
$20
$30
$30
$20
$30
30%
Urg
ent
Care
co-p
ay
$20
$30
$30
$20
$30
30%
Specia
lists
/Consultants
co-p
ay
$20
$30
$30
$20
$30
30%
Pre
nata
l, p
ostn
ata
l off
ice v
isit c
o-p
ay
$20
$30
$30
$20
$0
30%
Scans:
CT
, C
AT
, M
RI,
PE
T e
tc.
0%
10%
20%
$100/t
est
$0
30%
Dia
gnostic X
-ray &
Labora
tory
Pro
cedure
s
0%
10%
20%
$0
$0
30%
Infe
rtili
ty
(dia
gn
osis
/tre
atm
en
t o
f ca
use
s o
f in
fert
ility
su
bje
ct
to p
lan
be
ne
fits
)N
ot
co
ve
red
No
t co
ve
red
No
t co
ve
red
50
%
OV
co
pa
y o
r
ho
sp
ita
liza
tio
n
co
pa
y a
pp
ly
No
t co
ve
red
Pre
ventive C
are
(in
clu
de
s p
hysic
al e
xa
ms &
scre
en
ing
s)
0%
Ded W
aiv
ed
0%
Ded W
aiv
ed
0%
Ded W
aiv
ed
$0
$0
0%
Ded W
aiv
ed
HO
SP
ITA
L &
SK
ILL
ED
NU
RS
ING
FA
CIL
ITY
Em
erg
ency R
oom
vis
it
(wa
ive
d if
ad
mitte
d)
0%
$100 c
o-p
ay
10%
$100 c
o-p
ay
20%
$100 c
o-p
ay
$100
$100
30%
$100 c
o-p
ay
Inpatient
Hospital
(pre
au
tho
riza
tio
n r
eq
uire
d)
0%
10%
20%
$200/a
dm
it$0
30%
Outp
atient
Hospital
0%
10%
20%
$100/a
dm
it$30
30%
Surg
ery
, O
utp
atient
(pe
rfo
rme
d in
Su
rge
ry C
en
ter)
0%
10%
20%
$100
$30
30%
Surg
ery
, O
utp
atient
(pe
rfo
rme
d in
a H
osp
ita
l)0%
10%
20%
$100
$30
30%
Dis
tric
t N
am
eL
AK
E E
LS
INO
RE
UN
IFIE
D
Barg
ain
ing
Un
itC
ON
F M
GM
T/A
DM
IN
2018-2
019
An
them
An
them
An
them
An
them
Kais
er
An
them
10
0-D
$2
090
-C $
30
80
-G $
30
Pre
mie
r 20
Tra
d H
MO
$3
0A
nch
or
Bro
nze
ME
NT
AL
HE
AL
TH
& S
UB
ST
AN
CE
AB
US
E
INP
AT
IEN
T:
Facili
ty B
ased C
are
(p
rea
uth
re
qu
ire
d)
0%
10%
20%
$200
$0
30%
OU
TP
AT
IEN
T:
Facili
ty B
ased C
are
(p
rea
uth
re
qu
ire
d)
0%
10%
20%
$0
$30
30%
OT
HE
R S
ER
VIC
ES
Acupunctu
re
- Lim
its a
pply
0%
10%
20%
$10/3
0 v
isits
com
bin
ed
w/c
hir
o
$10/3
0 v
isits
com
bin
ed
w/c
hir
o
30%
Am
bula
nce (
Gro
und o
r A
ir)
0%
$100 c
o-p
ay
10%
$100 c
o-p
ay
20%
$100 c
o-p
ay
$100
$50
30%
$100 c
o-p
ay
Chir
opra
ctic
- Lim
its a
pply
0%
10%
20%
$10/3
0 v
isits
com
bin
ed w
/acu
$10/3
0 v
isits
com
bin
ed w
/acu
30%
Dura
ble
Medic
al E
quip
ment
(DM
E)
0%
10%
20%
20%
no c
harg
e30%
Physic
al and O
ccupational T
hera
py -
Lim
its a
pply
0%
10%
20%
$20
$30
30%
PH
AR
MA
CY
BE
NE
FIT
S
Pla
n9-3
520
0/1
0-3
520
0/1
0-3
520
0/1
0-3
5T
rad
H
MO
$3
0A
nch
or
Bro
nze R
x
Indiv
idual/F
am
ily B
rand &
Specia
lty R
x D
eductible
snone
$200/$
500
$200/$
500
$200/$
500
none
Inclu
ded w
/
Medic
al ded
Indiv
idual/F
am
ily R
x O
ut-
of-
(OO
P)
Max
(inclu
des R
x d
eductible
s a
nd c
o-p
ays)
$2,5
00/
$3,5
00
$2,5
00/
$3,5
00
$2,5
00/
$3,5
00
$2,5
00/
$3,5
00
Inclu
ded w
/ M
ed
OO
P M
ax
Inclu
ded w
/ M
ed
OO
P M
ax
Generi
c c
o-p
ay/3
0 d
ays s
upply
$0 a
t C
ostc
o
$9 a
t O
ther
Netw
ork
$0 a
t C
ostc
o
$10 a
t O
ther
Netw
ork
$0 a
t C
ostc
o
$10 a
t O
ther
Netw
ork
$0 a
t C
ostc
o
$10 a
t O
ther
Netw
ork
$10 u
p t
o 1
00
day s
upply
$9
Bra
nd c
o-p
ay/3
0 d
ays s
upply
$35
$35
$35
$35
$30 u
p t
o 1
00
day s
upply
$35
Specia
lty c
o-p
ay/u
p t
o 3
0 d
ays s
upply
$35 M
ust
Use
Navitus M
ail
$35 M
ust
Use
Navitus M
ail
$35 M
ust
Use
Navitus M
ail
$35 M
ust
Use
Navitus M
ail
$30 u
p t
o 1
00
day s
upply
$35
Ord
er
(Generi
c-B
rand c
o-p
ay/9
0 d
ays s
upply
)$0-$
90
$0-$
90
$0-$
90
$0-$
90
$10-$
30/u
p t
o
100 d
ay s
upply
$0-$
90
In this incentive plan, Delta Dental pays 70% of the contract allowance for covered basic services and major services during the first year of eligibility. The coinsurance percentage will increase by 10% each year (to a maximum of 100%) for each enrollee if that person visits the dentist at least once during the year. If an enrollee does not use the plan during the calendar year, the percentage remains at the level attained the previous year. If an enrollee becomes ineligible for benefits and later regains eligibility, the percentage will drop back to 70%.
Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26
Deductibles N/A
Deductibles waived for D & P? N/A
Maximums The maximum benefit paid per calendar year is $1,200* per person in-network (this amount includes the additional $200 for using a PPO dentist. See note above under Network)
The maximum benefit paid per calendar year is $1,000 per person out-of-network
Waiting Period(s) Basic Benefits
None
Major Benefits None
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for out-of-network dentists.
Delta Dental of California 100 First St. San Francisco, CA 94105
Customer Service 866-499-3001
Claims Address P.O. Box 997330 Sacramento, CA 95899-7330
deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.
Plan Benefit Highlights for: PPO Incentive ($1,200/$1,000) no Orthodontic
Group No 7475, 7076: Active, Retirees, and Cobra
Network: PPO/Premier *The plan provides an additional $200 toward the calendar year maximum when you visit a PPO dentist.Look for this information for the dentist of your choice on the Delta find a provider website to take advantage of this additional amount: (Other network affiliations: Delta Dental PPO)
Benefits and Covered Services*
Delta Dental PPO dentists** Non-Delta Dental PPO
dentists**
Diagnostic & Preventive Services (D & P)
Exams, 2 cleanings per cal year, x-rays
70-100 % 70-100%
Basic Services Fillings, simple tooth extractions, sealants
70-100 % 70-100%
Endodontics (root canals) Covered Under Basic Services
70-100 % 70-100%
Periodontics (gum treatment) Covered
Under Basic Services 70-100 % 70-100%
Oral Surgery Covered Under Basic Services
70-100 % 70-100%
Major Services Crowns, inlays, onlays, and cast restorations
70-100 % 70-100%
Prosthodontics Bridges, dentures, implants
50 % 50%
Dental Accident Benefits 100% (separate $1,000 maximum per person per calendar year)
CSEA-CONF MGMT
Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent children to age 26
Deductibles In-Network: N/A
Out-of-Network: $25 per person, $75 per family, per plan year
Deductibles waived for D & P? In-Network: N/A
Out-of-Network: No
Maximums The maximum benefit paid per calendar year is $2,000 per person in-network
The maximum benefit paid per calendar year is $1,000 per person out-of-network
Waiting Period(s) Basic Benefits
None
Major Benefits None
Orthodontics None
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists.
Delta Dental of California 100 First St. San Francisco, CA 94105
Customer Service 866-499-3001
Claims Address P.O. Box 997330 Sacramento, CA 95899-7330
deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your plan, please consult your company’s benefits representative.
Plan Benefit Highlights for: PPO $2,000 with Orthodontic- Preferred
Group No 7675, 7276, 7275: Active and Cobra, (Retirees - exclude Orthodontic)
Benefits and Covered Services*
In-PPO Network** Out-of-PPO Network**
Diagnostic & Preventive Services (D & P)
Exams, 2 cleanings, x-rays
100 % 50 %
Basic Services Fillings, simple tooth extractions, sealants
100 % 50 %
Endodontics (root canals) Covered Under Basic Services
100 % 50 %
Periodontics (gum treatment) Covered Under Basic Services
100 % 50 %
Oral Surgery Covered Under Basic Services
100 % 50 %
Major Services Crowns, inlays, onlays and cast restorations
100 % 50 %
Prosthodontics Bridges, dentures, implants
50 % 50 %
Orthodontic Benefits Adults and dependent children
100% 100%
Orthodontic Maximums Separate $3,000 Lifetime maximum per person
Dental Accident Benefits 100% (separate $1,000 maximum per person per calendar year)
50%
CSEA-CONF MGMT-LETA
SISC and VSP provide you an affordable eyecare plan.
Signature Plan C $20 with 2nd
Pair Glasses
Your Coverage from a VSP Doctor
WellVision Exam® focuses on your eye health and
overall wellness .......................... every calendar year Prescription Glasses Lenses ........................................ every calendar year • Single vision, lined bifocal, and lined trifocal
lenses.• Polycarbonate lenses for dependent children.
Frame ......................................... every calendar year • $150.00 allowance for frame of your choice• $170.00 allowance on featured frame brands• 20% off the amount over your allowance• $80.00 allowance at Costco
~OR~Contact Lens Allowance .......... every calendar year$105.00 allowance for contacts and the contact lens exam (fitting and evaluation).
~AND~ Second Pair This enhancement allows you to get a second pair of glasses or contacts, subject to a copayment
Extra Discounts and Savings
Glasses and Sunglasses
• Average 35 - 40% savings on all non-covered lensoptions
• 30% off additional glasses and sunglasses, includinglens options, from the same VSP doctor on thesame day as your WellVision Exam. Or get 20% offfrom any VSP doctor within 12 months of your lastWellVision Exam
Contacts
• 15% off cost of contact lens exam (fitting andevaluation)
Laser Vision Correction
• Average 15% off the regular price or 5% off thepromotional price. Discounts only available fromcontracted facilities.
• After surgery, use your frame allowance (if eligible)for sunglasses from any VSP doctor
Co-Payments – First Pair Benefit
Exam and Prescription Glasses Co-payment varies, contact VSP for additional information.
If you see a non-VSP provider, you’ll receive a lesser benefit. Before seeing a non-VSP provider, call us at 800.877.7195 for more details.
Out-of-Network Reimbursement Amounts: Exam ....................................................... Up to $35.00 Single vision lenses ................................. Up to $25.00 Lined bifocal lenses ................................. Up to $40.00 Lined trifocal lenses ................................. Up to $50.00 Frame ...................................................... Up to $30.00 Contacts .................................................. Up to $90.00
VSP guarantees service from VSP doctors only. In the event of a conflict between this information and your organization's contract with VSP, the terms of the contract will prevail.
CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | 1025 West Navitus Drive | Appleton, Wisconsin 54913
Share a Clear Viewnavitus.com
Have questions about your pharmacy benefi ts with Navitus Health Solutions? Visit
www.navitus.com for answers!
For information specifi c to your plan, visit Navi-Gate® for Members. Activate your
account online using the Member Login link and an activation email will be sent
to you. The site provides a wealth of information and is available 24 hours a day,
seven days a week. Navi-Gate for Members allows you to access personalized
pharmacy benefi t information online.
Some of the features offered include:
MY PRESCRIPTION BENEFITS
View general information about your pharmacy benefi t.
PHARMACY SEARCH
Find a participating pharmacy in your local area — search
for 24-hour pharmacies, and it provides a map to help you
fi nd a pharmacy.
DRUG SEARCH
Learn about prescription and over-the-counter drugs, how
they are used, warnings and more.
HEALTH INFO
Keep on top of important health news and information.
MAIL ORDER
Learn about available mail order options, if applicable to your pharmacy benefi t.
WHAT’S MY COPAY?
Determine your estimated cost for specifi c prescriptions.
NAVI-GATE® FOR MEMBERSPharmacy Benefi t Information at Your Fingertips
Navi-Gate for
Members Offers
Easier Access
to Your
Prescription
Benefi t
Information
N1045-1213
CUSTOMER CARE: 24 HOURS A DAY, 7 DAYS A WEEK | 1025 West Navitus Drive | Appleton, Wisconsin 54913
Share a Clear Viewnavitus.com
MEDICATION HISTORY
Medication history is displayed for enrollees and dependents in the form of a table for a
specifi ed date range.
DRUG INTERACTIONS
Understand how the effect of a particular drug is altered when taken with another
drug or food. Contains thousands of drug interactions between prescriptions, over-the-
counter drugs, as well as herbal, vitamin and nutritional products. Includes severity
rankings so steps can be taken to lessen harmful effects.
Please contact Navitus Customer Care if you have any additional questions or concerns.
We hope you fi nd Navi-Gate for Members informative and useful.
TO ACCESS, GO TO: WWW.NAVITUS.COM > MEMBERS > MEMBER LOGIN
���������� ����������
���������������������������������������������� �!��"���#��$%�����������&'" '���&�������������������!������(
������)��*��� ���*&!���������+��������������,�� &��������������������-�"�"��������..�����#��.$
��������/�����0��������1�"!������������2���+������$
�$�������� �!��&�������������*�����,�����!.����*�*"����.����#��������!*"��,�#������.��������*�,���.�.�������"������3** .. 4$�)������!��� �&!�&����,� �!�����������"����/�.���������&�����*�����!�����.��������������������������.�����������.��&�� �.$�����/�0������!�$1
�����5�!������������������ �!��!�����*����.�&������.$���6�,� �!������������������!��� �7!���������.�&��8�.�������������&��.����������$�5�!������"��&��*&��.����������� �!������!��� �7!���������� �!�������� �!��&������.$���������������������������������������������+������ �!���'*�����..�������������8����**!����������������������� ����*�!�$��+�� �!���!�.���/����������8���..���������'*����������.�����&����������������.�����&��.!��������*�����,�����/�����"�6$�����/�0������!�$1
������+�� �!���8��&������&�������8����������������*� �!����������������*�.��������� �!�������������������.�����*�.��������.������� �!���8�$�+���!.�����.� ��*������&������!*"������"����������.����&������&�����7!����������*��!&$�����/�0������!�1���.�0���#�*$1
������2���� ,��������!��� �&!�&����,����#�*� �!��!�����*����.�&������.,��������02���+�1����"�������/�����.8��������������������������� �!��"���#��$
�����*�9�!������������������.����*�����9�!���������������������$������*�9�!����������.������*�9�!��������2������.�%������+��!��������*&�� �������.�&��.���������������������9�!�������������������$�:���;%���������������.����.�*��/���������*�+��!��������*&�����,�+��$�;���9�!����������*����.�� *"����������������.�*��/���������9�!�������������������$
������������� �����!���������������"#����#�������$���������%&��'�(��) �&*����������������
����������
Exceptional Care,Anywhere.
Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. MDLIVE phone consultations are available 24/7/365, while video consultations are available during the hours of 7 am to 9 pm 7 days a week or by scheduled availability. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit www.mdlive.com/pages/terms.html 010113
Pediatric Care
■ Cold & Flu■ Constipation■ Ear Infections■ Nausea■ Pink Eye■ And More!
24/7/365 on-demand access to affordable, quality healthcare. Anytime, Anywhere.
With MDLIVE, you can visit with a doctor 24/7 from your home, office or on the go. Our network of Board Certified doctors is available by phone or secure video to assist with non-emergency medical conditions.
Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today.
Download the App
When should I use MDLIVE?
Instead of going to the ER or an urgent care center for a non-emergency issue
During or after normal business hours, nights, weekends and even holidays
If your primary care doctor is not available
To request prescription refills (when appropriate)
If traveling and in need of medical care
How much does it cost?Your copay for this service is:
Who are our doctors?
MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.
MDLIVE.com/SISC 1-888-632-2738
$5*All enrolled SISC PPO members and Anthem HMO members.
Common Conditions We Treat■ Allergies■ Asthma■ Bronchitis■ Cold & Flu■ Diarrhea■ Ear Infections■ Fever■ Headache■ Infections
■ Insect Bites■ Joint Aches■ Rashes■ Respiratory Infections■ Sinus Infections■ Skin Infections■ Sore Throat■ Urinary Tract Infections■ And More!
Are my children eligible?
Yes. MDLIVE has pediatricians on call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors.
Exceptional Care, Anywhere.
Personalized “Concierge” support for PPO Plan members
Access to top-quality surgeons at Scripps
No medical bills! Co-insurance and deductibles are waived
Eligible procedures include:
Knee Replacement
Hip Replacement
Spinal Fusion
Travel expenses are covered
Contact us at:1-888-855-7806
Need surgery? Get the care you deserve with your new Carrum Health benefit!
Who is eligible for the program?SISC members on PPO plans with eitherAnthem Blue Cross or Blue Shield.Members must satisfy clinical guidelines forspecific covered procedures.
This benefit is exclusive to ScrippsHospital and must be accessed throughCarrum Health.
Which procedures are covered?Eligible procedures include:
a. Hip Replacementb. Knee Replacementc. Cervical Spinal Fusiond. Lumbar Spinal Fusion
Please contact Carrum Health to determine if your procedure is eligible.
How do I qualify for these services?The following criteria must be met to qualify forthe Carrum Health program:
a. You have primary medical coverage through aSISC PPO plan.
b. You meet requirements of the hospitalphysician(s) considering your case. Additionaldiagnostic or medical services may berequired.
c. Your local physician agrees to assume carefor you upon return home.
d. You have an adult caregiver physically able toassist you during your care and travel, if travelis needed.
Personalized “Concierge” support Access to top-quality surgeons at
Scripps No medical bills! Co-insurance and
deductibles are waived* Travel expenses are covered
*Due to IRS regulations, on HSA plans thedeductible applies but coinsurance is waived
What is Carrum Health and how does it benefit me?
Carrum Health is a special surgery benefit that provides exclusive access to“Centers of Excellence”. These hospitals and doctors provide for an
improved patient experience and top-quality, more affordable care.
Introducing a new surgery
benefit for PPO members
that covers:
hip/knee replacements and
many inpatient spine surgeries!
Which services and expenses are covered?Coverage includes the following:
a. All eligible medical expenses associated withyour evaluation or procedure at the hospital.
b. Travel expenses for you and one adultcompanion including transportation, lodging,and a daily allowance.
c. Medically necessary services or equipmentrelated to this program provided after dischargefrom the hospital before returning home(excluding outpatient medication).
Which travel expenses are covered?The following expenses are covered for you andone companion:
a. Transportation – air, train, bus, rental car ormileage allowance (if driving your own car).
b. Lodging – one hotel room to be shared by youand one adult companion.
c. Meals – a daily allowanced. Parking and baggage fees – as appropriate.
Who manages my travel?Your personal Care Concierge will make all travelarrangements for you and one adult companion.
What forms do I need to complete? Do Ineed to provide medical records?Upon verification of eligibility, your Care Conciergewill help you complete the acknowledgement,authorization and medical records release forms.After that, your Care Concierge takes care ofgathering and transferring all your medical recordsto your chosen hospital.
What about recovery care post-discharge?Your Care Concierge will coordinate all follow-up care on your behalf, including developmentof your personalized post-discharge care plan,scheduling of all related services and smoothlytransitioning you back into your SISC PPO planfor continuing coverage. Your Care Conciergewill confirm the availability of follow-up carebefore you visit the hospital for the procedure.
Do I need to have a relationship with a localphysician for recovery care?Yes. In order to be eligible for the program, youmust have an established relationship with alocal physician. Your physician must be willingto assume ongoing care once you return home.Your Care Concierge will gather your homephysician’s contact information and facilitatearrangements for all necessary follow-up careon your behalf.
How do I participate in the program?If your doctor has recommended surgery, youcan contact Carrum Health by calling1-888-855-7806. A Care Concierge will beassigned to you and he/she will help verify youreligibility, assist you in selecting a hospital anddoctor and begin coordinating the clinical visitsand travel logistics, if necessary. Your CareConcierge will continue supporting youthroughout the entire episode of care.
To learn more about Carrum Health:
Call toll-free 1-888-855-7806
Mak
e su
re y
ou’re
getti
ngth
e rig
ht c
are,
righ
t now
Wha
t are
you
r he
alth
con
cern
s?
Ask
us a
nyth
ing.
It’s
free
, it’s
eas
y,it’
s 10
0% confidential.
855.
201.
9925
Expe
rt M
edic
al
Opi
nion
s
Our
doc
tors
hav
e th
e tim
e an
d fr
eedo
m to
hel
p yo
u an
d yo
ur fa
mily
one
-to-
one,
to h
elp
you
unde
rsta
nd
wha
t’s h
appe
ning
, how
to n
avig
ate
the
heal
thca
re
syst
em, a
nd g
et th
e be
st a
nsw
ers
to y
our b
igge
st
ques
tions
, with
out d
elay
.
With
a fo
cus
on re
latio
nshi
p-ba
sed
care
, our
pr
ogra
m b
rings
med
icin
e ba
ck to
its
hum
an ro
ots
as
a ca
ring
prof
essi
on.
Rela
tions
hips
sa
ve li
ves
Whe
n it’
s yo
ur
love
d on
es, i
t matt
ers
Whe
n th
e he
alth
of a
love
d on
e is
at s
take
, you
’ll
wan
t to
know
that
the
wor
ld’s
lead
ing
expe
rts
are
look
ing
for t
he b
est a
nsw
ers.
We
less
en th
e bu
rden
of
car
ing
for a
sic
k fa
mily
mem
ber,
by g
etting
to th
e co
rrec
t dia
gnos
is a
nd re
com
men
ding
the
optim
al
cour
se o
f tre
atm
ent.
It’s
free
, it’s
eas
y, a
nd it
’s 10
0% c
onfid
entia
l.
adva
nce-
med
ical
.net
/sis
csi
sc@
adva
nce-
med
ical
.net
Page
5
Your
per
sona
l tea
m
hand
les
ever
ythi
ngA
sk A
Doc
tor
Any
thin
g
Find
ing
the
Righ
t Exp
erts
Hel
p w
ith
Dai
ly D
ecis
ions
Mov
e Fo
rwar
d w
ith C
onfid
ence
Dr.
Jose
ph K
anna
mC
ardi
olog
ist
Dr.
C.E
. Nw
ogu
Thor
acic
Sur
geon
Dr.
Elai
ne Ja
ffe
Hem
atop
atho
logi
st
Your
cas
e is
man
aged
by
a Ph
ysic
ian
Cas
e M
anag
er. Y
ou h
ave
dire
ct a
cces
s to
him
or h
er fo
r as
long
as
you
need
hel
p.
We
prov
ide
VIP-
leve
l con
cier
ge
serv
ice
to e
very
pro
gram
par
ticip
ant
in o
ur c
are.
Our
focu
s is
iden
tifyi
ng
the
best
doc
tors
for a
ny g
iven
co
nditi
on a
nd d
evel
opin
g id
eal c
are
plan
s ba
sed
on th
eir e
xper
tise.
Your
Phy
sicia
n C
ase
Man
ager
sta
ys
with
you
as
a pa
rtne
r in
ever
yday
de
cisio
n m
akin
g, g
ivin
g yo
u tim
ely
pers
onal
ized
advi
ce.
Phys
ician
Cas
e M
anag
er a
nd E
xper
ts
wor
k to
geth
er to
revi
ew y
our c
ase
and
crea
te a
cus
tom
ized
cour
se fo
r tr
eatm
ent.
Our
repo
rts
help
you
un
ders
tand
you
r tre
atm
ent,
and
can
prov
ide
clea
r dire
ctive
s to
you
r tr
eatin
g ph
ysic
ian.
A Ph
ysic
ian
Cas
e M
anag
er n
ever
co
nsid
ers
a ca
se “c
lose
d” u
ntil
all y
our q
uesti
ons
have
bee
n an
swer
ed.
Adva
nce
Med
ical
mat
ches
pati
ents
to d
octo
rs
who
are
the
lead
ing
expe
rts
on th
eir s
peci
fic
cond
ition
s. O
ur d
octo
rs w
ork
with
you
to g
et
the
right
dia
gnos
is, a
nd re
com
men
d th
e be
st
path
for t
reat
men
t.
Expe
rtise
mak
es
all t
he d
iffer
ence
It st
arts
with
the
right
dia
gnos
is
It en
dsw
ith p
eace
of m
ind
Dr.
Anul
i Mkp
aru,
O
rtho
pedi
c Su
rgeo
n an
dPh
ysic
ian
Cas
e M
anag
erfo
r Adv
ance
Med
ical
age
4/5:
3-5
/8 o
r 3.
625
*In accordance with federal and state law, and professional ethical standards.
Have there been a few bumps in the road?
Have questions about home, work or family?
How we can help
When you or a household member contacts us, we’ll workwith you to figure out the next steps. If you need counseling,we can arrange several free visits with a licensedprofessional. If you have money or legal questions, we canput you in touch with a financial advisor or a lawyer.
}} Workplace safety}} Child and elder care resources}} Tobacco cessation
}} Grief and loss}} Family health}} Home improvement
}} Addiction and recovery}} Dealing with identity theft
Employee Assistance Program
Maybe you’re a few months behind on bills and want to getback on track. Or you’re new to town and looking for a daycarecenter. Whatever your concern, a call to the EmployeeAssistance Program (EAP) can help you through it.
What is EAP anyway?
You may have heard about EAP but aren’t sure what it is. EAPis a service available to you and members of your householdat no extra cost. It’s designed to help you with everydayproblems and questions, big or small. No need to fill outpaperwork or make an appointment to speak with an EAP staffmember. Just call 800-999-7222 or visit anthemEAP.com.You’ll be connected in an instant, and we’re here 24 hours aday, every day, to help you.
If online help is more your style, visit anthemEAP.com. You’llfind articles, checklists, quizzes and other helpful tools. Youcan browse resources, attend a webinar or take an onlineclass—right at your own desk. Here are just some of the topicscovered:
Remember, EAP is here for you 24/7, so you can call at the time and place that are right for you. Your privacy is important tous. No one will know you’ve called EAP unless you give them permission in writing.*
EAP can help smooth it out. Call 800-999-7222
or go to anthemEAP.com and enter SISC.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name andsymbol are registered marks of the Blue Cross Association.
MCASH3151ABC 2/12
Section 125 PlanUnderstanding Your Employer’s Section 125 Plan
SB-15310-1016
9000 Cameron Parkway • Oklahoma City, OK 73114 800-654-8489 • americanfidelity.com
1 If you are subject to FICA tax, there might be a slight reduction in your social security benefit due to the reduction of FICA contributions. Example is for illustrative purposes only. Please consult your tax advisor for actual tax savings.
See How Much You Could SaveThis example shows what a sample employees’ bi-weekly paycheck could look like when using a Section 125 Plan. The sample is based on 24 pay periods.
Did You Know?Figure out how much you could save with our Section 125 calculator by visiting American Fidelity Assurance Company’s website, americanfidelity.com.
Plan Today for Tomorrow’s Expenses
With a Section 125 Plan Without a Section 125 PlanGross Bi-Weekly Income $2,000.00 Gross Bi-Weekly Income $2,000.00
Insurance Premiums- Medical insurance
- Dental insurance- Vision insurance
- Cancer insurance- Accident insurance
- Health Flexible Spending Acct
-$250.00-$30.00-$25.00-$20.00-$15.00-$50.00
Less Tax- Federal & State at 20%
- FICA at 7.65%-$400.00-$153.00
Taxable Bi-Weekly Income $1,610.00 Bi-Weekly Income Before Benefits $1,447.00Less Tax
- Federal & State at 20%- FICA at 7.65%
- $322.00- $123.17
Insurance Premiums- Medical insurance
- Dental insurance- Vision insurance
- Cancer insurance- Accident insurance
- Out-of-pocket medical expenses
-$250.00-$30.00-$25.00-$20.00-$15.00-$50.00
Net Bi-Weekly Salary $1,164.83 Net Bi-Weekly Salary $1,057.00
If there was a program available that could save you money on your taxes and help you proactively plan for out-of-pocket expenses, would you take advantage of it? That’s exactly what a Section 125 Plan does – reduces your taxes and increases your spendable income. Under a Section 125 Plan, employers can offer eligible benefits to employees, through payroll deduction, on a pre-tax basis.
This employer-sponsored program is designed to help you save money on important expenses like eligible insurance premiums, health-related expenses, and dependent day care expenses.
S P E C I A L I Z I N G I N S U P P L E M E N T A L B E N E F I T S F O R Y O U R I N D U S T R Y
Confidential/Administrator-Benefit DirectoryAnthem PPO Anthem HMO
Group #: 40656 D,F,GBronze 2-Tier Anchor: Emp.+Child(ren)
Member ID#: Located on front of Card Customer Service: 1-800-825-5541
Blue Cross of California
Navitus: 1-866-333-2757 www.navitus.com
Costco Mail Order: 1-800-607-6861 www.pharmacy.costco.com www.anthem.com/ca/sisc
PO Box 60007
Los Angeles, CA 90060
MD Live (PPO Members Only) : 1-888-632-2738
www.mdlive.com/sisc
Group #: 57AGTE & 57AGTN (Prior Select) Member ID#: Printed on Card Customer Service: 1-800-825-5541
www.anthem.com/ca/sisc
Blue Cross of California – California Care
P.O. Box 629
Woodland Hills, CA 91365
KAISER PERMANENTE Chiropractic Network for Kaiser & Anthem Group #: 231876-0005 Member ID#: Medical Record # on your card
Membership Info Center: 1-800-464-4000
www.kaiserpermanente.org
Kaiser Permanente Medical Care
Program Membership Information Center
P.O. Box 41920
Los Angeles, CA 90041
American Specialty Health Plans (ASHP)
No Referral is needed from Primary Physician
To confirm your provider is a participating chiropractor, call 1-
800-678-9133 Mon. thru Friday 5:00 a.m. to 6:00 p.m.
DELTA DENTAL VISION PLAN
Delta Dental Incentive (PPO) 7079-7076
Delta Preferred Option (PPO) 7079-7276 Member ID#: Employee’s Social Security #
Customer Service (CMS): 1-866-499-3001
Internet: www.deltadentalins.com
E-mail: [email protected]
For a printed list of Delta dentists in your area:
1-800-427-3237 or visit the internet site.
Vision Service Plan 2499598AMember ID#: Employee’s Social Security #
VSP: Customer Service: 1-800-877-7195 Internet: www.VSP.com
MES: Customer Service: 1-800-877-6372
Internet: www.MESVision.com
Voluntary Products AMERICAN FIDELITY 125 FLEXDisability/Accidental/Life Plans/CancerAmerican FidelityAccount Representative: Ester Garcia 1-866-523-1857 Disability Claims: 1-800-662-1113Reimbursement Accts: 1-800-654-8489www.afadvantage.com AflacAgent: Mary Isaacs [email protected]
Employee Assistance Program (EAP) LIFE INSURANCE
EAP services may be obtained by calling the 24-hour
toll-free number 1-800-999-7222. www.anthemeap.com
Metlife : 800-638-5433$50,000 per employee
$200,000 for Administrators
Member ID#: Employee’s Social Security #
NOTE: Contact Safety & Risk Services if wish to purchase
supplemental Term Life insurance.
Supplemental/AD&D: 800-654-8347Julie Scranton, Safety & Risk Services Supervisor-ext. 5281
Cara Quinn, Safety & Risk Services Secretary-ext. 5380
Unreimbursed Medical/Dependent Care-Voluntary
Enrollment in Aug/Sept each year, reps come to school sites.
Plans & deductions effective January 1st of each year.
Navitus: 1-866-333-2757 www.navitus.com
Costco Mail Order: 1-800-607-6861 www.pharmacy.costco.com
This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official plan and insurance
documents govern your right and benefits under each plan. For more details about your benefits, including a complete list of exclusion and limitations, please refer to each carrier’s EOC. The EOC’s are available on the District Website under “Employee Benefits.” www.leusd.k12.ca.us
Lake Elsinore Unified School District
Board of Education
Stan Crippen
Superintendent Dr. Doug Kimberly
LEUSD Benefits Team
Julie Scranton
Safety & Risk Services Supervisor
Cara Quinn
Safety & Risk Services Secretary
Contact Information: [email protected]
Safety & Risk Services Department
(951) 253-7000
Extension-1x5380
Susan E. Scott
Heidi Matties Dodd
Juan I. Saucedo
Christopher McDonald
